0:00

This was a young adult who had weakness

0:04

in the upper extremities.

0:07

We have here the T1-weighted,

0:08

T2-weighted, STIR, and post-gadolinium enhanced scans.

0:11

On the T1-weighted scan,

0:14

we have a low signal intensity lesion which

0:16

shows bright signal intensity on the T2-weighted

0:18

scan and the STIR images,

0:21

and the cord appears to be expanded.

0:24

On the post-gadolinium enhanced scan,

0:27

we see that there is indeed contrast enhancement

0:30

in somewhat of a peripheral nature.

0:33

This is an example of a case where, frankly,

0:35

I would not be able to distinguish between a

0:37

neoplastic lesion, an inflammatory lesion,

0:41

or a demyelinating lesion.

0:43

All of them can cause cord expansion and usually

0:47

show some element of contrast enhancement if

0:51

it's an active demyelinating process

0:55

within the demyelinating disorders.

0:57

Because it is a long-segment

0:59

disease that expands three segments,

1:01

we would have to consider something.

1:03

like neuromyelitis optica.

1:06

Within the inflammatory infectious etiologies,

1:09

there are any number of viral myelitis that can

1:13

cause cord expansion and cord enhancement.

1:17

The next step in this patient

1:21

would be to do CSF sampling.

1:24

The CSF sampling may be useful for CSF cytology,

1:27

although for spinal cord lesions,

1:29

it's not all that high yield.

1:32

But you would include the demyelinating markers

1:38

within the CSF, including myelin basic protein,

1:42

among others. And you would do your culture

1:45

and cells that may help you identify a bacterial

1:50

or a viral myelitis.

1:53

This particular case ended up being...

1:57

I'm sorry, an idiopathic acquired

2:00

transverse myelitis. That is,

2:03

they never discovered any viral illnesses.

2:06

the patient did not have any

2:07

antecedent illnesses,

2:09

the patient did not have an autoimmune disorder.

2:12

And with steroids, this lesion resolved.

2:16

Sometimes when you're looking at spinal

2:18

cord lesions like this one,

2:20

you're in multiple categories of disease,

2:22

including neoplastic, demyelinating,

2:25

and infectious inflammatory,

2:26

and you just have to throw up your hands and say,

2:29

'Recommend evaluation of the cerebrospinal fluid.'

2:34

Besides throwing our hands up and recommending

2:37

CSF sampling, what else could we do as radiologists?

2:40

In this situation, it would be helpful to recommend

2:44

evaluation of the brain and the remainder of the

2:48

spinal cord evaluation. Why so? Well,

2:51

if you saw multiple periventricular and

2:53

subcortical lesions in the brain,

2:56

you may go back to a demyelinating

2:58

process that would suggest something like

3:02

multiple sclerosis or neuromyelitis optica,

3:05

or other demyelinating disorders.

3:08

Similarly,

3:09

if you found additional lesions in the spinal

3:12

cord below the cervical region at

3:15

the mid to lower thoracic spine,

3:17

it might also suggest a demyelinating disorder,

3:20

since that would be unusual for myelitis,

3:23

which is usually a solitary lesion.

3:25

You'd still have the category of neoplasm with

3:28

multifocal astrocytomas or ependymomas

3:32

if the patient had, for example,

3:34

neurofibromatosis type 1 or

3:36

neurofibromatosis type 2.

3:38

So in addition to recommending CSF sampling,

3:41

recommend evaluation of the brain for other

3:44

demyelinating lesions or the remainder

3:47

of the spinal cord.